Chapter 6 Maternal Child Nursing Care

Naegle's rule - estimate due date

**BE Careful of THE YEAR!!!!!** Begin with the first day of the LMP (first day) Subtract 3 months, and add 7 days EDC, EDD,EDB - Estimated date of birth,confinement, delivery

Trimesters of pregnancy

- 1st trimester: week 1-13 - 2nd trimester: week 14-26 - 3rd trimester: week 27-40

Reordering personal relationships

-Close relationships of the pregnant woman undergo change as she prepares emotionally for the new role of mother. -Promoting effective communication patterns between the expectant mother and her own mother and between the expectant mother and her partner are common nursing interventions provided during the prenatal visits. -The woman's relationship with her mother is significant in adapting to pregnancy and motherhood. -Although the woman's relationship with her mother is significant in considering her adaptation in pregnancy, the most important person to the pregnant woman is usually the father of her child.

Describe fetal circulation

-Placenta -Umbilical vein -Ductus venosus (liver) -Inferior vena cava -Right atrium ---Foramen ovale to left atrium ---Right ventricle to pulmonary artery to ductus arteriosus -Aorta -Peripheral circulation -Umbilical arteries -Placenta The pattern of supplying the highest levels of oxygen and nutrients to the head, neck, and arms enhances the cephalocaudal (head to rump) development of the fetus.

Prenatal Visit 28 weeks

1 hour gluclose tolerance test 3 hours gluclose tolerance test Blood work ( hematocrit and syphilis) Rh neg = rhogam injections

Mesoderm systems

1. Bones 2. Muscles 3. Dermis and connective tissue 4. Cardiovascular system and spleen 5. Urogenital system

Three Primary Germ layers

1. Ectoderm 2. Mesoderm 3. Endoderm

Ectoderm systems

1. Epidermis 2. Glands 3. Nails and hair 4. CNS/PNS 5. Lens of the eye 6. Tooth enamel 7. Lower amniotic cavity

Endoderm systems

1. Epithelial lining of resp. and digestive tract 2. liver an d pancreas 3. Urethra, bladder, and vagina 4. Roof of the yolk sac

Process of Conception

1. Gamete (sperm, egg) formation 2. Ovulation - release of the egg 3. Union of gamete - results in embryo 4. Implantation in the uterus

Length of pregnancy

10 lunar months 9 calendar months 40 weeks 280 days

prenatal care visits

16-20 weeks Quad screen Sonogram for fetal anomalies - gender can be revealed

Sufficient surfactant available

32 weeks sufficient surfactant available in alveoli for viability

Physiological adaptations of cervix during pregnancy

6 weeks Goodell sign - normal, softening of the cervix Friability - tissue is easily damaged - can cause slight bleeding after vaginal exam or after sex 16-18 weeks Ballottement- passive movement of unengaged fetus Quickening- feeling fetus move

Initial prenatal visit

8-10 weeks Prenatal Interview Physical Examination Lab tests - PAP Gonorrhea/Chlamydia cultures, blood type, antibody screen (rH neg = rhogam shots), hematocrit, syphilis, hepatits B, HIV, rubella, thyriod, urinalysis Sign consent forms Review pregnancy modifications - diet, exercise First trimester sonogram (10 weeks) for dating Cystic fibrosis screening Review Genetic testing options

Hydramnios

>2L of amniotic fluid Associated with GI abnormalities.

Maternal Adaptation stages

Accepting pregnancy Identifying with the mothering role Reordering personal relationships Establishing relationship with fetus Preparing for childbirth

Describe the yolk sac

Aids in transferring maternal nutrients and oxygen, which have diffused through the chorion, to the embryo. Blood cells and plasma are manufactured in the yolk sac during the 2nd and 3rd weeks while uteroplacental circulation is being established and is forming primitive blood cells until the hematopoietic activity begins. The folding in of the embryo during the 4h week results in incorporation of part of the yolk sac into the embryo's body as the primitive digestive system.

Fetal Respiratory System

Begins developing in week 4, movements visualized as early as week 11 Fetal lungs produce fluid that expands air spaces in lungs Shortly before birth, secretion of lung fluid decreases Vaginal birth squeezes out 1/3 of fluid Infants born via C/S do not have this so may have more respiratory issues at birth Pulmonary surfactants, which line aveoli to keep inflated, are sufficient by 32 wks Detection of surfactants in amniotic fluid can be used to determine fetal lung maturity

Physiological adaptation of renal system during pregnancy

Bladder irritability, nocturia, and urinary frequency and urgency are common in early pregnancy Urinary frequency results initially from increased bladder sensitivity and later from compression of the bladder Glomerular filtration rate (GFR) increases by 50% during 1st trimester and remains elevated throughout pregnancy Changes caused by pregnancy hormones, increased blood volume, and woman's posture, physical activity and nutritional intake Increased GFR = increased creatine clearance and a reduction in serum creatine, blood urea nitrogen (BUN) and uric acid levels Fluid and electrolyte shifts d/t increase in fluid Routine urine screens - protein, glucose, ketones Further testing- creatine/protein ration, UA/UC Serum Tests- BUN, Creatine, Uric Acid Side lying position maximizes renal efficiency - left side - increase urine output and decreases edema

Physiological adaptations of cardiovascular system during pregnancy

Cardiac output increases 30-50% reaching peak at week 25-30 and then declining to 20% increase at 40 weeks. Total blood volume (TBV) increases significantly during pregnancy by 40-50%. Pregnancy is considered a hypercoagulation state in which women are at 5-6X increased risk for thromboembolic disease. Supine hypotensive syndrome/vena cava syndrome = Cardiac output is reduced by as much as 25-30% when a pregnant woman is turned from left lateral recumbent to supine position contributes to the dependent edema, varicose veins in the legs and vulva, and hemorrhoids that can develop in later part of term pregnancy Also contributes to the increased risk for VTE

What is the first organ system to function in developing human?

Cardiovascular system

What happens during the ovum stage of development

Cellular replication Blastocyte formation Initial development of embryonic membranes Establishment of germ layer

Physiological adaptation of vagina and vulva during pregnancy

Chadwick sign- violet blue vaginal mucosa and cervix (6-8wks) d/t increased vascularity Leukorrhea- vaginal discharge increases (whitish/grey) d/t increase in estrogen and progesterone - never pruritic or blood stained Operculum- mucus plug - fills the endocervical canal Lower pH- helps prevent ascending bacterial infections of the uterus - women is more vulnerable to other infections like candidiasis or bacterial vaginosis Connective tissue loosens Increase vascularity of the vagina results in heightened sensitivity that can lead to high degree of sexual interest

Physiological adaptations of the neurologic system during pregnancy

Compression of nerves - increased pain carpal tunnel syndrome - edema tension headaches Postural hypotension - d/t vasomotor instability or hypoglycemias hypocalcemia can cause muscle cramps or tetany

Physiological changes of respiratory system during pregnancy

Congestion/ Sinus stuffiness- d/t increased vascularity from elevated levels of estrogen causing edema and hyperenmia ( nosebleeds/epitaxis, voice changes) Maternal oxygen consumption increases during pregnancy by 20-40% above nonpregnant levels. Chest breathing replaces abdominal breathing and it becomes less possible for the diaphragm to descend w/ inspiration Tidal volume (amount of air exchanged during normal inspiration and expiration) increases by 40% during pregnancy. Pregnancy is a state of chronic hyperventilation w/ reduced arterial carbon dioxide (PaCO2) and increased oxygen (PaO2) over nonpregnant levels There are alterations in acid-base balance which creates a state of resp. alkalosis and facilitate the transport of CO2 from the fetus to the mother and the O2 from the mother to the fetus.

Estimated date of birth

Determined based on the date of the woman's last menstrual period and the first accurate ultrasound exam. Important for planning prenatal care, scheduling specific prenatal screening tests, assessing fetal growth, and making critical decisions for managing pregnancy complications. Most accurate assessment of EDB is based on ultrasound measurement of the embryo or fetus during the 1st trimester

Describe the umbilical cord

During the 3rd week, the blood vessels develop to supply the embryo w/ maternal nutrients and oxygen. During the 5th week, the embryo has curved inward on itself from both ends and brings the connecting stalk to the ventral side of the embryo. Two arteries carry blood from the embryo to the chorionic villi and one vein returns blood to the embryo. At term, the cord is 2 cm in diameter and ranges in 30-90cm in length. Wharton's Jelly = connective tissue that prevents compression of the blood vessels and ensures continued nourishment of the embryo/fetus. Nuchal cord = when the cord is wrapped around the fetal neck Battledore placenta = when the cord is peripherally located on the placenta.

Establishing a relationship with the unborn child

Emotional attachment begins during the prenatal period as women use fantasizing and daydreaming to prepare themselves for motherhood The mother-child relationship progresses through pregnancy as a developmental process that unfolds in 3 phases: Phase 1 - woman accepts the biologic fact of pregnancy. She needs to be able to state, "I am pregnant". The woman's thoughts center on herself and the reality of the pregnancy. Phase 2 - The woman accepts the growing fetus as distinct from herself. Usually accomplished by the 5th month. Woman can state, "I am having a baby". Differentiation of the child from the woman's self-permits the beginning of the mother-child relationship that involves not only caring but also responsibility. Phase 3 - the woman prepares realistically for the birth and parenting of the child. Woman states, "I am going to be a mother".

Describe the special characteristics that enable the fetus to obtain sufficient oxygen from the maternal blood

Fetal hemoglobin carries 20-30% more oxygen than maternal hemoglobin The hemoglobin concentration of the fetus is about 50% greater than the mother The fetal heart rate (FHR) is 110-160 beats/min, making the cardiac output per unit of body weight higher than that of an adult.

How fetus gets O2

Fetal hgb carries 20-30% more O2 than maternal hgb Fetal hgb concentration 50% more than maternal concentration FHR 110-160 bpm, higher cardiac output than adult

Accepting the Pregnancy (Maternal)

First step is accepting the idea of pregnancy and assimilating the pregnant state into the woman's way of life. The degree of acceptance is reflected in the woman's emotional response. Women who are happy and pleased about the pregnancy often view it as a biologic fulfillment and part of their life plan. A woman can be upset or dislike being pregnant and still feel love for the child to be born Emotional liability = rapid and unpredictable changes in mood are common and can be surprising. Most women have ambivalence (having conflicting feelings simultaneously) feelings during pregnancy whether pregnancy was intended or not Intense feelings of ambivalence that persists through the 3rd trimester can indicate an unresolved conflict w/ the motherhood role

Amniotic fluid

Fluid surrounding baby comprised of diffusion from maternal blood, and secretions from the fetal respiratory and GI systems. Increases weekly to around 700-1000 mL at term.

Every prenatal visit

Focused physical assessment -Vital signs, especially blood pressure -Weight and presence of edema -Fundal height - uterine growth -Fetal heartbeat -Fetal movements and presentation Urinalysis for glucose, albumin, ketones (dipstick) Pelvic exam or sterile vaginal exam if indicated -Education

Weight gain in pregnancy

For women with single fetuses, current recommendations are that women w/ normal BMI should gain 25-35 lbs 1st trimester = average total weight gain is 2-4 lbs 2nd and 3rd trimesters = weight gain should increase by 1lb per week

Umbilical cord

Forms during the 5th week Two arteries carry blood away from the embryo One vein returns blood to the embryo Wharton's jelly - Connective tissue that prevents compression of blood vessels and ensures continued nourishment of the embryo/fetus Nuchal cord - When the cord is wrapped around the fetal neck

Development of embryo

From 15 days to 8 weeks. Most important time for organ development Most vulnerable to malformation d/t teratogens Amnion and Chorion form. Chorion covers placenta and contains major umbilical blood vessels Amnion forms the amnionic sac

Physiological adaptations of the breasts during pregnancy

Fullness - heaviness, tingling, increased sensitivity due to increase in estrogen and progesterone Nipples more erect and stiff and darken Striae gravudarum - stretch marks Colostrum - Prolactin (produced by anterior pituitary gland) stimulates production of colostrum by the end of the first trimester. 2nd trimester = human placental lactogen stimulates secretion of colostrum. By 16th week = breasts are prepared for full lactation. Lactation is inhibited until progesterone level decreases after birth.

Prenatal visit 36 weeks

Group Beta Strep - tests if antibiotics are required during labor Pelvic exam to check if cervix is ready for birth

Function of amniotic fluid

Helps maintain constant body temperature Fluid and electrolyte balance Cushions fetus from trauma Acts as barrier to infection

What is human chorionic gonadotropin (hCG)?

Hormone produced by women shortly after conception-present so the body can sustain pregnancy. Home pregnancy tests detect this - can be detected 8-10 days after conception

What hormones are made by placenta

Human chorionic gonadotropin (hCG) Human chorionic somatomammotropin (hCS) Human placental lactogen (hPL) Progesterone Estrogen

Physiological adaptations of integumentary system during pregnancy

Hyperpigmentation = stimulated by melanotropin (anterior pituitary hormone) which is increased during pregnancy. Darkens the nipples, areolae, axillae, and vulva around the 16th week Melasma (chloasma/mask of pregnancy) = a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead, esp. in darker skinned women Sun intensifies pigmentation Linea nigra = a pigmented line extending from the symphysis pubis to the tip of the fundus in the midline. Begins in the 3rd month and keeps pace w/ the rising height of the fundus (primigravida) or appears in the 3rd month in its entirety (multigravidas) Striae gravidarum (stretch marks) appear in 50-80% of pregnant women during the 2nd half of pregnancy Angiomatas (vascular spiders) = tiny starshaped or branched, slightly raised, and pulsating end-arterioles usually found on the neck, thorax, face, and arms. Appear during the 2nd to 5th month as a result of increased flood flow to the skin d/t rising estrogen levels and usually disappear w/in 3 months postpartum Palmar erythema = pinkish red, diffusely mottled, or well-defined blotches d/t increased estrogen levels. The most common dermatologic symptom during pregnancy is itching (pruritis) Pruritus gravidarum = mild itching = usually occurs over the abdomen Polymorphic eruption of pregnancy (PEP) - AKA pruritic urticarial papules and plaques of pregnancy (PUPPP) = the most common specific dermatosis during pregnancy. Dermatitis More common in multiple gestations Can cause significant maternal discomfort but is not associated w/ adverse outcomes for mom or fetus. Mild is typically tx'ed w/ oral antihistamines and topical antipruritic and corticosteroid creams. Nail and hair growth may be accelerated. Hirsutism = excessive growth of hair or growth of hair in unusual places is common

Describe the maternal placental embryonic circulation

In place by day 17 When embryonic heart starts beating no direct link b/w fetal blood in the vessels of the chorionic villi and the maternal blood in the intervillous spaces. Placental function depends on the maternal blood pressure supplying circulation. At term, 10% of maternal cardiac output goes to the uterus. When a woman lies on her back w/ the pressure of the uterus compressing the vena cava, blood return to the right atrium is diminished. Optimum circulation is achieved when the woman is lying at rest on her side.

Oligo-hydramnios

Lower than normal volume of amniotic fluid. <300 mL Usually associated with fetal renal abnormalities.

Preparing for the birth experience

Many women actively prepare for birth by reading books and information on various websites, watching videos, attending parenting classes, and talking to other women. Anxiety can arise from concerns about a safe passage for herself and her child during the birth process

Multifactorial genetic malfunctions

Most common genetic malfunction Caused by environment and genetic factors Examples: Cleft lip/palate, congenital heart disease, neural tube defects, pyloric stenosis

What occurs during embryo phase?

Most critical time in the development of the organ systems and the main external features. Developing areas w/ rapid cell division are most vulnerable to malformation caused by environmental teratogens. End of 8th week = all organ systems and external systems are present, and embryo is unmistakably human

Risk factors for genetic problems

Mother > 35 yo Father > 50 yo Family history of thalassemia, neural tube defects, Downs syndrome, congenital heart defects, Tay-Sachs, Canavan Fam. hist of sickle cell, hemophilia, MD, CF, HD, mental retardation, or any other genetic, chromosomal defects History of diabetes or phenylketonuria Previous miscarriage or stillbirth

hegar sign

Occurs around 6 weeks gestation - softening and compressibility of the lower uterine segment (uterine isthmus) occurs

3 stages of intrauterine development

Ovum/Pre-embryonic conception-day 14 Embryo - Day 15 to 8 weeks Fetus 9 weeks- end of gestation

3 phases characterizing the developmental tasks experienced by the expectant father:

Phase 1 - announcement phase = lasts from a few hours to a few weeks. Task is to accept the biological fact of pregnancy. Phase 2 - moratorium phase = the period where he adjusts to the reality of pregnancy. Task is to accept the pregnancy. Can be relatively short or persist until the last trimester Phase 3 - focusing phase = begins in the last trimester and is characterized by the father's active involvement in both the pregnancy and his relationship with his child. Task is to negotiate w/ his partner the role he is to play in labor and to prepare for parenthood. He starts to think of himself as a father.

How long does the placenta continue to grow?

Placenta continues to grow wider until 20th week, when it covers about half of the uterine surface. Then grows thicker

Rapid weight gain in pregnancy may indicate what?

Pre-eclampsia

Signs of pregnancy

Presumptive = subjective changes reported by the women. Can be caused by conditions other than pregnancy. Ex: amenorrhea, fatigue, breast changes Probable = objective changes assessed by an examiner. When combined with the presumptive s/s, these changes strongly suggest pregnancy Ex: Hegar sign, ballottement, pregnancy tests Positive = objective signs assessed by an examiner that can be attributed only to the presence of the fetus. These are definitive signs that confirm pregnancy Ex: hearing fetal heart tones, visualizing the fetus, palpating fetal movements.

Physicological adaptations of endocrine system during pregnancy

Progesterone and estrogen = key in pregnancy Oxytocin = key in labor Prolactin = key in lactation

Physiological changes of musculoskeletal system in pregnancy

Relaxin and progesteron - cause loosening of ligaments of the pubic symphysis and sacroiliac joints to facilitate labor and birth Diastasis recti abdominis = the separating of the rectus abdominus muscles allowing abdominal contents to protrude at the midline. Center of gravity shifts, which can result in aching, numbness, and back pain d/t compensation of ligaments and increase in normal spine curvature.

Describe the metabolic functions of the placenta

Respiration, nutrition, excretion and storage Oxygen diffuses from the maternal blood across the placental membrane into the fetal blood, and CO2 diffuses in the opposite direction. Carbs, proteins, calcium, and iron are stored in the placenta for ready access to meet fetal needs. Water, inorganic salts, carbs, proteins, fats, and vitamins pass from maternal blood supply across the membrane into fetal blood. Water and most electrolytes readily diffuse through the membrane Fetal concentration of glucose is lower than the glucose level in maternal blood b/c of its rapid metabolism by the fetus. Metabolic wastes cross the placenta membrane for the maternal kidneys to excrete.

Postconception age

Since conception occurs approx 2 weeks after the first day of the LMP, the post conception age is two weeks less than length of pregnancy. Conception to delivery 266 days.

Ductus arteriosus

Special circulatory pathway that performs the function of the lungs in the fetus.

Maternal-placental-embryonic circulation

Starts by day 17 Maternal blood supplies O2 and nutrients to embryo across placental membrane CO2 diffuse into maternal blood in opposite direction Placenta functions as "lungs" for fetus

What does progesterone do during pregnancy?

Steroid hormone. Maintains the endometrium Decreases the contractility of the uterus Stimulates maternal metabolism and development of breast alveoli.

Describe amniotic fluid

The amniotic cavity initially derives its fluid by diffusion from the maternal blood. Fluid secreted by the respiratory and GI tracts of the fetus also enters the amniotic cavity Amount of fluid increases weekly: 700-1000mL is normally present at term Beginning at week 11, the fetus urinates and increases volume Fluid helps maintain a constant body temp. Serves as a source of oral fluid and as a repository for waste and assists in maintenance of fluid and electrolyte homeostasis. Keeps the embryo from tangling w/ the membranes, facilitating symmetric growth.

How often do prenatal visits occur?

The initial visit usually occurs in the 1st trimester, w/ monthly visits through week 28 of pregnancy. Thereafter, visits are scheduled Q 2 weeks until week 36 and then weekly until birth.

parity

The number of pregnancies in which the fetus or fetuses have reached 20 weeks of gestation, not the number of fetuses born. Not effected by whether the fetus is born alive or is born stillborn

Identifying with the mother role

The process of identifying w/ the mother role begins early in each woman's life when she is being mothered as a child. Many women have always wanted a baby, liked children, and looked forward to motherhood = high motivation to become a parent promotes acceptance of pregnancy and eventual prenatal and parental adaptation.

Physiological adaptation of GI system in pregnancy

Up to 70% of pregnant women experience nausea w/ or w/o vomiting (morning sickness), possibly in response to increasing levels of hCG and altered carb metabolism Nausea and vomiting of pregnancy (NVP) appear at about 4-6 weeks and subsides by the end of the 3rd month Pica = craving of nonfood things. Ex: ice, clay, and laundry starch Should be considered as a potential factor in cases of iron deficiency anemia or poor weight gain The gums can become hyperemic, spongy, and swollen during pregnancy. They tend to easily bleed d/t increased levels of estrogen. Increased progesterone causes decreased tone and motility of smooth muscles, resulting in reflux, slower emptying time of the stomach, and reverse peristalsis. Constipation - d/t progesterone & estrogen, iron supplements -ok to use stool softeners

Lab tests during pregnancy

Urine, cervical, and blood samples are obtained during the initial visit for a variety of recommended screening and diagnostic tests for infectious diseases and metabolic conditions. All pregnant women should receive human immunodeficiency virus (HIV) risk reduction counseling and be notified that they will be tested for antibody to HIV as part of the routine prenatal resting unless they decline the test. CDC recommends testing during initial visit for syphilis, chlamydia, and hep B. Screening for HIV, syphilis, chlamydia, and gonorrhea is repeated in the third trimester for women who are at high risk Purified protein derivative (PPD) tuberculin test may be administered to assess exposure to TB in women who are high risk Urine is tested for protein, glucose, and leukocytes. Urine culture may also be done During pelvic exam - PAP smear and culture for chlamydia and gonorrhea is done

Implantation

Usually occurs 6-10 days after fertilization. Blastocyst implants itself in the endometrium. May have slight spotting or bleeding at the time of the first missed menstrual period.

Physiological changes of uterus during pregnancy

Uterus is a muscle - changes shape size and position Fundal height - measured in cm, after week 16 should be about same as gestation wks i.e. gestation wk 36 = fundal height 34-38 Braxton hicks - practice contractions - after 4th month of pregnancy Pregnancy beings to show after 14 weeks

Fertilization

When the sperm penetrates the membrane surrounding the ovum. Takes place in outer third of uterine tube. The ovum then becomes impenetrable to other sperm. The nuclei fuse forming one diploid pair of chromosomes known as a zygote.

Preterm

a pregnancy that has reached 20 weeks of gestation but ends before completion of 37 weeks of gestation

post term

a pregnancy that has reached 42 weeks 0 days and beyond of gestation

late preterm

a pregnancy that has reached between 34 weeks 0 days and 36 weeks 6 days

early term

a pregnancy that has reached between 37 weeks 0 days and 38 weeks 6 days of gestation

full term

a pregnancy that has reached between 39 weeks 0 days and 40 weeks 6 days of gestation

late term

a pregnancy that has reached between 41 weeks 0 days and 41 weeks 6 days of gestation

uterine souffle

a rushing or blowing sound of maternal blood flowing through uterine arteries to the placenta that is synchronous w/ the maternal pulse

primipara

a woman who has completed one pregnancy with a fetus or fetuses who have reached 20 weeks gestation or more

multipara

a woman who has completed two or more with a fetus or fetuses who have reached 20 weeks gestation or more

nulligravida

a woman who has never been pregnant

nullipara

a woman who has not completed a pregnancy with a fetus or fetuses who have reached at least 20 weeks gestation

What is viability?

capacity to live outside the uterus (22-25 weeks)

primigravida

first pregnancy

Hormones produced by placenta

hCG, hCS, progesterone, estrogen

Braxton Hicks contractions

irregular and painless contractions that occur intermittently throughout pregnancy

Ballottement

passive movement of the unengaged fetus. Can be identified by an examiner b/w 16th and 18th week.

Gravidity

pregnancy

Gravida

pregnant woman

What is the ductus arteriosus?

special circulatory pathway that bypasses the lungs d/t them not able to function for respiratory gas exchange

funic souffle

synchronous w/ the fetal heart rate and is caused by fetal blood coursing through the umbilical cord.

intimate partner violence

tends to worsen during pregnancy. Risk factors for IPV during pregnancy include younger age (esp. adolescents), unintended pregnancy, lower income, and lower level of education Screening should be done at the initial visit, once every trimester, and at the postpartum visit The Abuse Assessment Screen is simple and widely used.

Couvade syndrome

the experiencing of pregnancy symptoms by male partners; sometimes called "sympathy pains" - (nausea, weight gain, and other physical symptoms)

lightning

the fetus begins to descend into the pelvis in preparation for birth

Quickening

the first recognition of fetal movements, or "feeling life:" Can be detected by multiparous woman b/w 14-16 weeks and nulliparous woman 18 weeks or later.

When is the structure of the placenta complete?

week 12

multigravida

woman who has been pregnant more than once